Immune checkpoint inhibitors are used in metastatic melanoma with good efficacy and safety profile. We report the first case of an inflammatory demyelinating disease of the central nervous system during treatment with Pembrolizumab and discuss the evidence in the literature supporting its causative role. The patient had a good clinical recovery after intravenous steroids, plasma exchange and discontinuation of Pembrolizumab. Due to the expected increase in the importance of immune checkpoint inhibitors in cancer treatment, it is important to be aware of neurological adverse events, as early treatment usually leads to good clinical responses.
INTRODUÇÃOO melanoma primário pode afetar diversas estruturas oculares, desde a pálpebra, conjuntiva, úvea (coroideia, corpo ciliar e íris) e muito raramente a órbita, sendo responsável por cerca de 3% -5% de todos os melanomas. [1][2][3][4][5][6][7] É importante referir que o melanoma intraocular (também designado melanoma da úvea) é considerado uma identidade diferente do melanoma cutâneo e da conjuntiva. O primeiro tem origem nos melanócitos da mesoderme e metastiza por via hemática, em contraste com o tumor da pele e mucosas que tem origem na ectoderme e metastiza, preferencialmente, por via linfática. 4É sobre o melanoma primário da coroideia, que corresponde a 85% dos melanomas oculares, que incide este trabalho de revisão. Em comparação com o melanoma da íris, apresenta pior prognóstico e melhor que o melanoma do corpo ciliar. 1,4,6Epidemiologia e fatores de risco O melanoma da coroideia é o tumor intraocular maligno primário mais comum no adulto, e o segundo tipo de melanoma primário mais frequente, imediatamente após o melanoma cutâneo. Estima-se uma incidência anual de aproximadamente 4 -10 casos por 1 milhão de habitantes. 1,2,3,6,[8][9][10] É mais frequente na sexta década de vida e, ao contrário do que se observa na maioria das neoplasias, a sua incidência parece decrescer em idades mais avançadas. Distribui-se igualmente em ambos os sexos, com predileção por indivíduos de pele e olhos claros. 1,4,7,11Acredita-se que a maioria dos melanomas da coroideia se desenvolva a partir de nevus pré-existentes, embora o crescimento de novo também possa ocorrer.Outros factores de risco são a melanocitose congéni-ta ocular e óculo-dérmica, síndrome de nevus displásico e neurofibromatose tipo 1. Não há evidência científica consistente quanto ao papel da radiação ultravioleta, ao contrário do que ocorre nos casos de melanoma da pele e mucosas. 4,5,7,8,[11][12][13] Apresentação clínicaAs manifestações clínicas são inespecíficas e não contribuem para o diagnóstico, sendo muitas vezes um achado acidental num exame oftalmológico de rotina.Numa fase inicial os doentes são assintomáticos, mas quando o tumor atinge grandes dimensões ou se localiza próximo ao nervo óptico ou mácula, pode causar queixas de baixa visão, miodesópsias e fotópsias. A dor é rara e um sintoma sugestivo de mau prognóstico. 4,5,7,10,11,13 Ao exame oftalmológico, o melanoma da coroideia apresenta-se como uma lesão elevada subretiniana, geralmente única e unilateral, com uma coloração que varia de amelanocítica (15% -20%) a pigmentada castanho-acinzentada, sendo raramente preto escuro. Tem uma conformação nodular (75%) (Fig. 1), em cogumelo (20%) (Fig. 2) ou difusa (5%). Subjacente ao tumor é possível observar alterações do epitélio pigmentado da retina como atrofia,
Exudative retinal detachment occurs when fluid accumulates between the neurosensory retina and the retinal pigment epithelium. Ocular diseases or multisystem conditions such as nephrotic syndrome may lead to exudative retinal detachment. This report describes a case of nephrotic syndrome secondary to minimal change disease, anasarca and bilateral serous macular detachment in an adult patient. A 75-year-old male patient presented to the emergency department with generalized edema, asthenia, and visual impairment. Medical history included a recent diagnosis of nephrotic syndrome secondary to minimal change disease, which had been controlled with corticosteroid therapy. At presentation, best corrected visual acuity was 20/100. Slit-lamp examination revealed xanthelasmas and mild bilateral eyelid edema and chemosis. Dilated fundus examination confirmed bilateral macular detachment. The patient did not respond to diuretic therapy. Ttherefore, hemodialysis was started. Two months later, visual acuity improved to 20/25 and near normal restoration of retinal anatomy was achieved, with concurrent remission of proteinuria. Exudative retinal detachment is a multifactorial condition. However, in diseases associated with severe hypoalbuminemia, such as nephrotic syndrome, low oncotic pressure in choroidal vessels and high interstitial pressure in the choroid may explain retinal detachment. Patients with chronic kidney disease carry a high risk of ophthalmic disease development. Several mechanisms that affect ocular vessels, the retina and the choroid are thought to be involved. A multidisciplinary approach is crucial to resolve the ophthalmic condition and improve overall health.
Introduction: Fuchs' Uveitis (FU) is a chronic nongranulomatous anterior uveitis that accounts for 3% of all uveitis cases. Usually is asymptomatic but occasionally can cause floaters and decrease in visual acuity secondary mainly to complications like vitreous opacities, cataract and glaucoma. The diagnosis is clinic and treatment includes correction of complications. Presentation of Case: 40-year-old woman presented with a complaint of progressive decreased vision in the right eye (OD). Slit lamp evaluation revealed in OD multiple stellate keratic precipitates, slight iris atrophy and hypochromia, a white cataract and no anterior chamber inflammatory reaction. Intraocular pressure in OD was high and was controlled with timolol. On the basis of these findings and after excluding other aetiologies, a diagnosis of Fuchs' uveitis was made. Cataract surgery was performed. Conclusion: This clinical case enhances the need of integration of clinical signs to don't sub diagnosis Fuch's uveitis and not overvalue the presence of iris heterochromia. This cases also reflect the good results obtained with cataract surgery associated with few complications in this type of uveitis.
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